2017-10-16T17:02:39-05:00 2016-12-31 420714325 RSM US LLP 201 N HARRISON STREET SUITE 300 DAVENPORT IA 528011999 990 2016-01-01 420842204 PELLA REGIONAL HEALTH CENTER PELL 6416283150 404 JEFFERSON STREET PELLA IA 50219 ROBERT KROESE CHIEF EXECUTIVE OFFICER 6416283150 2017-10-13 1 JOHN J ROMANO P00227323 5638884000 2016 2022-09-23 18:48:47Z ROBERT KROESE 404 JEFFERSON STREET PELLA IA 50219 228944667 0 X WWW.PELLAHEALTH.ORG X 1958 IA TO PROVIDE HEALTHCARE AND HEALING SERVICES WITH CHRISTIAN COMPASSION. 10 8 876 172 31904 -7009 184478 222169 77690282 80517331 3032587 5590460 5168406 5143022 86075753 91472982 5321 4195 0 0 45897866 47749544 0 0 0 34468037 36202489 80371224 83956228 5704529 7516754 135898925 142692983 53306138 54592044 82592787 88100939 X THE MISSION OF PELLA REGIONAL HEALTH CENTER IS TO PROVIDE HEALTHCARE AND HEALING SERVICES WITH CHRISTIAN COMPASSION. 0 0 69289380 4195 85052781 PELLA REGIONAL HEALTH CENTER (PRHC) IS A 25-BED ACUTE CARE HOSPITAL LOCATED IN PELLA, IOWA. THE HEALTH CENTER ALSO OPERATES CLINICS IN MONROE, SULLY, NEW SHARON, KNOXVILLE, NEWTON, BUSSEY, ALBIA, AND OTTUMWA, IOWA. ANNUALLY, THE HEALTH CENTER HAS OVER 1,500 ADMISSIONS, OVER 530 LIVE BIRTHS, OVER 10,600 EMERGENCY CENTER VISITS, AND PERFORMS OVER 5,700 SURGERIES.PELLA REGIONAL HEALTH CENTER LEADS IN THE DELIVERY OF HEALTHCARE SERVICES TO ITS REGION WITH OVER 800 ASSOCIATES (INCLUDING 30 PHYSICIANS) WHICH COORDINATE PATIENT CARE AS AN INTEGRATED UNIT. PRHC AND ITS ASSOCIATES WORK SEAMLESSLY TO MEET THE NEEDS OF THE COMMUNITIES THEY SERVE.THE ACCOMPLISHMENTS WHICH FOLLOW ARE ATTRIBUTABLE TO PRHC AND ITS AFFILIATES AS A WHOLE.PRHC ALSO MAKES MEDICAL CARE ACCESSIBLE TO THE ENTIRE REGION IT SERVES. PRHC OPERATES A FULL-TIME EMERGENCY ROOM AND PROVIDES EMERGENCY CARE REGARDLESS OF ABILITY TO PAY. THE HEALTH CENTER PROVIDES THE CLINICAL/ANCILLARY SERVICES REQUIRED TO OPERATE THE EMERGENCY CENTER AND PROVIDES FULL-TIME ON-SITE EMERGENCY MEDICAL SERVICES. IN MARCH OF 2015, PELLA REGIONAL HEALTH CENTER PURCHASED CROWN PHARMACY AND OPENED A RETAIL PHARMACY.IN ADDITION, PELLA REGIONAL HEALTH CENTER, THROUGH ITS INTEGRATED NETWORK OF PROVIDERS, PROVIDES NON-EMERGENCY SERVICES TO THE REGION IT SERVES. PRHC MAKES THESE SERVICES ACCESSIBLE TO THE REGION THROUGH PARTICIPATION IN GOVERNMENT PROGRAMS LIKE MEDICARE AND MEDICAID AND BY OFFERING ASSISTANCE THROUGH THE PRHC'S CHARITY CARE PROGRAM.PRHC PROVIDES CARE TO PATIENTS AND RESIDENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. BECAUSE PRHC DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. THE AMOUNT OF CHARGES FOREGONE FOR SERVICES PROVIDED UNDER PRHC'S CHARITY CARE POLICY WAS APPROXIMATELY $697,000 FOR THE YEAR; ENDED DECEMBER 31, 2016. TOTAL DIRECT AND INDIRECT COSTS RELATED TO THESE FORGONE CHARGES WERE $349,000 AT DECEMBER 31, 2016 BASED ON AN AVERAGE RATIO OF COST TO GROSS CHARGES.PRHC ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPPORTING OR FINANCIALLY VIABLE.PELLA REGIONAL HEALTH CENTER TAKES ITS MISSION TO IMPROVE THE HEALTH AND THE QUALITY OF LIFE OF THE PEOPLE IT SERVES A STEP FURTHER BY REACHING OUT TO MEET THE BROAD HEALTH NEEDS OF THE REGION IT SERVES. THE HEALTH CENTER STRIVES TO IDENTIFY THE NEEDS OF THE REGION BEYOND BASIC HEALTHCARE, AND THEN RESPONDS TO THEM BY AIMING TO MAKE A POSITIVE, LIFE-ENHANCING DIFFERENCE IN THE REGION. PRHC TAKE A STRATEGIC, REGIONAL NEEDS BASED APPROACH TO DELIVERING BENEFITS TO THE REGION. ADMINISTRATION HAS RESPONSIBILITY FOR LEADING THE ORGANIZATION TO ACHIEVE THE FOLLOWING OBJECTIVES:1) TO COLLABORATE WITH LOCAL LEADERSHIP COMMITTEES TO IDENTIFY UNMET COMMUNITY HEALTH NEEDS AND UNDER-SERVED POPULATIONS THROUGHOUT THE REGION2) TO ADDRESS UNDERSERVED POPULATIONS WITH UNMET NEEDS THROUGHOUT THE REGION3) TO IMPLEMENT, COORDINATE, AND PROVIDE STRATEGIC MANAGEMENT OF PRHC'S COMMUNITY BENEFIT EFFORTS4) TO IMPROVE THE OVERALL HEALTH OF ALL COMMUNITIES THROUGHOUT THE REGION.THIS POSITION LINKS ALL COMMUNITY BENEFIT ACTIVITIES UNDER ONE MANAGEMENT UMBRELLA WITH A CONSISTENT CONTACT POINT. ORGANIZATIONAL FOCUS ON COMMUNITY BENEFIT HAS BEEN ELEVATED BY STRENGTHENING INFRASTRUCTURE TO SUPPORT AND COMMUNICATE COMMUNITY BENEFIT WORK. 744658 346737 PELLA REGIONAL HEALTH CENTER OPERATES A 15-BED SKILLED NURSING FACILITY FOR INDIVIDUALS WHO NEED REHABILITATION SERVICES OR THOSE WHO SUFFER FROM SERIOUS OR PERSISTENT HEALTH ISSUES THAT ARE TOO COMPLICATED TO BE TENDED TO AT HOME OR AT AN ASSISTED LIVING FACILITY.SKILLED CARE PROVIDES PATIENTS WITH THE OPPORTUNITY TO TRANSITION SMOOTHLY AND SAFELY FROM AN ACUTE HOSPITAL SETTING TO SKILLED CARE AND FINALLY TO THEIR HOMES OR PREVIOUS LIVING ENVIRONMENT.THE ORGANIZATION'S STAFF PROVIDE:-24 HOUR NURSING CARE UNDER THE SUPERVISION OF A REGISTERED NURSE-MEDICATIONS AND TREATMENTS ADMINISTERED AS PRESCRIBED BY A PHYSICIAN-INDIVIDUALIZED CASE MANAGEMENT FOR ALL PATIENTS-REHABILITATION SERVICES SUCH AS PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, RESPIRATORY THERAPY, CERTIFIED WOUND NURSES, AND INTRAVENOUS THERAPY-NUTRITION AND PHARMACEUTICAL COUNSELING-SOCIAL SERVICES AND SPIRITUAL SERVICES-LABORATORY, EMERGENCY, AND MEDICAL IMAGING 70034038 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 37 0 1 876 1 1 1 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X BRUCE HEIFNER 6416286603 404 JEFFERSON STREET PELLA IA 50219 X JAMES BRANDL PRESIDENT 0.50 0.20 X X 0 0 0 ROD BRAUN VICE PRESIDENT 0.50 X X 0 0 0 MARY GLENDENING DIRECTOR 0.50 X 0 0 0 DOUG KANIS DO DIRECTOR 40.00 X 390279 0 37216 JOHN KOOLSTRA SECRETARY 0.50 X X 0 0 0 MIKE LIND DIRECTOR 0.50 X 0 0 0 MIKE MORGAN TREASURER 0.50 X X 0 0 0 JOHN VANDER WERT DIRECTOR 0.50 X 0 0 0 CRAIG WITTENBURG MD DIRECTOR 40.00 X 457665 0 40734 TIMOTHY YODER DVM DIRECTOR 0.50 0.20 X 0 0 0 BRUCE HEIFNER CHIEF FINANCIAL OFFICER 40.00 X 161957 0 24348 ROBERT KROESE CHIEF EXECUTIVE OFFICER 40.00 2.00 X 288087 0 33970 YVONNE O'BRIEN-EVANS CHIEF NURSING OFFICER 40.00 X 157414 0 17687 MICHAEL THOMPSON DO DIRECTOR 40.00 X 416295 0 37615 CHARLES CANEDY MD PHYSICIAN 40.00 X 422149 0 36788 SPENCER CARLSTONE MD PHYSICIAN 40.00 X 391677 0 37561 JOSEPH COLEMAN MD PHYSICIAN 40.00 X 362835 0 37917 DALE LENSING MD PHYSICIAN 40.00 X 359718 0 40472 MATTHEW MORGAN DO PHYSICIAN 40.00 X 535329 0 37561 3943405 0 381869 60 0 1 0 GRAHAM CONSTRUCTION COMPANY 421 GRAND AVENUE DES MOINES IA 50309 CONSTRUCTION 2059595 SHIVE HATTERY INC PO BOX 1599 CEDAR RAPIDS IA 52406 ARCHITECTURE 666523 SIEMENS FINANCIAL SERVICES PO BOX 2083 CAROL STREAM IL 60132 EQUIPMENT RENTAL CONTRACT 603474 RSM US LLP 5155 PAYSPHERE CIRCLE CHICAGO IL 60674 ACCOUNTING 530490 SIEMENS MEDICAL SOLUTIONS PO BOX 120001 DEPT 0733 DALLAS TX 75312 EQUIPMENT MAINTENANCE CONTRACT 399579 25 189904 13242 19023 222169 PATIENT SERVICE REVENUE 621110 81859809 81859809 LONG-TERM CARE REVENUE 623990 346737 346737 LESS: PROVISION FOR UNCOLLECTIBLE 900099 -1689215 -1689215 80517331 1713472 1713472 237777 8846 228931 228931 228931 141136256 203571 136767887 694952 4368369 -491381 3876988 3876988 OTHER OPERATING REVENUE 900099 2757609 2757609 PHARMACY REVENUE 446110 2156482 2124578 31904 4914091 91472982 85399518 31904 5819391 4195 4195 2063268 1554905 508363 37692324 31029245 6663079 2061506 1671853 389653 3431524 2635150 796374 2500922 2002837 498085 92141 1435 90706 122225 122225 8876 8876 151434 151434 7937816 5016705 2921111 289583 261041 28542 5376823 4680159 696664 1164434 1094512 69922 195471 190006 5465 345006 275734 69272 2344721 2344721 5271887 5271887 639612 119590 520022 MEDICAL SUPPLIES 11798187 11798187 FOOD 352592 3149 349443 DUES AND MEMBERSHIPS 110252 77298 32954 MISCELLANEOUS EXPENSE 1429 1429 83956228 70034038 13922190 0 1338261 3736633 10075065 11904438 763514 837106 1268838 1527434 113061345 63323937 49862405 49737408 69588181 72678809 1600 0 326167 223167 2674894 2047988 135898925 142692983 5588869 7004555 45755000 44715000 760234 490785 1202035 2381704 53306138 54592044 X 82585287 88093439 7500 7500 82592787 88100939 135898925 142692983 7516754 -2008602 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8876 8876 0 PART II-B, LINE 1: LOBBYING EXPENDITURES RELATED TO MEMBERSHIP DUES INCLUDED: 21% OF MEMBERSHIP DUES PAID TO THE IOWA HOSPITAL ASSOCIATION, OR $6,756, AND 22.12% OF MEMBERSHIP DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION, OR $2,120. 7500 7500 7500 7500 7500 7500 7500 158 158 7500 7500 7500 0.00000 1.00000 0.00000 0 0 4523287 4523287 88511 78845458 42365137 36568832 25333871 20235393 5098478 4270218 723407 3546811 49737408 ESTIMATED CLAIMS PAYABLE 576000 BOND ISSUANCE COSTS 507026 THIRD PARTY SETTLEMENTS 385047 DEFERRED COMPENSATION 913631 2381704 X PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS IS TO SERVE THE PURPOSE OF THE RESTRICTIONS PLACED ON THE FUNDS BY THE RESPECTIVE DONORS. PART X, LINE 2: PELLA REGIONAL HEALTH CENTER (THE HEALTH CENTER) AND PELLA HOSPITAL FOUNDATION (THE FOUNDATION) ARE ORGANIZED AS IOWA NONPROFIT CORPORATIONS AND HAVE BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE HEALTH CENTER AND FOUNDATION ARE EACH ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THEY ARE SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO THEIR EXEMPT PURPOSE. THE HEALTH CENTER AND FOUNDATION BELIEVE THAT THEY HAVE APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING THEIR ANNUAL FILING REQUIREMENTS, AND AS SUCH, DO NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE HEALTH CENTER AND FOUNDATION WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. 1 1 X 1 X 1 X 0 1 0 1 1 323748 0 323748 0.00390 6788493 5039331 1749162 0.02080 7112241 5039331 2072910 0.02470 730579 2582 727997 0.00870 204046 20822 183224 0.00220 24838450 16567516 8270934 0.09850 4195 0 4195 0.00000 25777270 16590920 9186350 0.10940 32889511 21630251 11259260 0.13410 56647 56647 0.00070 56647 56647 0.00070 0 1689215 22434338 24053654 -1619316 X 1 1 1 1 PELLA REGIONAL HEALTH CENTER 404 JEFFERSON STREET PELLA IA 50219 WWW.PELLAHEALTH.ORG 630165H X X X X PELLA REGIONAL HEALTH CENTER 1 0 0 1 X X X X X X X X 14 1 0 0 1 X WWW.PELLAHEALTH.ORG/ABOUT-US/COMMUNITY/ X 1 14 1 WWW.PELLAHEALTH.ORG/ABOUT-US/COMMUNITY/ 0 1 X 200.000000000000 200.000000000000 X X X X 1 1 X X X 1 X WWW.PELLAHEALTH.ORG/PATIENTS-VISITORS/BILLING/FINANCIAL-ASSISTANCE/ X WWW.PELLAHEALTH.ORG/PATIENTS-VISITORS/BILLING/FINANCIAL-ASSISTANCE/ X WWW.PELLAHEALTH.ORG/PATIENTS-VISITORS/BILLING/FINANCIAL-ASSISTANCE/ X X X X X 1 X 0 X X X X X 1 X 0 0 PELLA REGIONAL HEALTH CENTER PART V, SECTION B, LINE 5: EACH COMMUNITY HAS A WEALTH OF EXPERTISE TO BE TAPPED FOR CHNA DEVELOPMENT. FOR THIS REASON, A TOWN HALL IS THE PERFECT FORUM TO GATHER COMMUNITY INSIGHT AND PROVIDE AN ATMOSPHERE TO OBJECTIVELY BUILD CONSENSUS AND PRIORITIZE COUNTY HEALTH ISSUES.ALL TOWN HALL PRIORITY-SETTING AND SCORING PROCESSES INVOLVE THE INPUT OF KEY STAKEHOLDERS IN ATTENDANCE. INDIVIDUALS AND ORGANIZATIONS ATTENDING THE TOWN HALLS WERE CRITICALLY IMPORTANT TO THE SUCCESS OF THE CHNA.THE FOLLOWING LIST OUTLINES PARTNERS INVITED TO TOWN HALL: LOCAL HOSPITALS, PUBLIC HEALTH COMMUNITY, MENTAL HEALTH COMMUNITY, FREE CLINICS, COMMUNITY BASED CLINICS, SERVICE PROVIDERS, LOCAL RESIDENTS, COMMUNITY LEADERS, OPINION LEADERS, SCHOOL LEADERS, BUSINESS LEADERS, LOCAL GOVERNMENT, FAITH-BASED ORGANIZATIONS AND PERSONS (OR ORGANIZATIONS SERVING THEM), PEOPLE WITH CHRONIC CONDITIONS, UNINSURED COMMUNITY MEMBERS, LOW INCOME RESIDENTS, AND MINORITY GROUPS. PELLA REGIONAL HEALTH CENTER PART V, SECTION B, LINE 11: THE 2014 IMPLEMENTATION PLAN DESCRIBES THE FOLLOWING NEEDS THAT WILL BE ADDRESSED IN THE FUTURE:1) INCREASE OUTPATIENT MENTAL HEALTH SERVICES AND SUBSTANCE ABUSE. PELLA REGIONAL HEALTH CENTER (PRHC) WILL CONTINUE PARTNERSHIPS WITH MENTAL HEALTH AGENCIES, EXPLORE GRANTS, INCREASE PATIENT AND STAFF KNOWLEDGE, AND RECRUIT PSYCHIATRIC PROVIDERS IN THE IMMEDIATE AREA.2) INCREASE INPATIENT MENTAL HEALTH SERVICES. PRHC WILL INCREASE OUTPATIENT SERVICES TO PREVENT THE NEED FOR INPATIENT SERVICES AND INCREASE PATIENTS AND PROVIDER/STAFF AWARENESS OF AVAILABLE SERVICES.3) FIGHT OBESITY AND FOCUS ON FITNESS, NUTRITION, AND PREVENTION ACTIONS. PELLA REGIONAL WILL PROMOTE FITNESS AND HEALTHY LIFESTYLES FOCUSING ON ACCESSIBLE FITNESS FACILITIES, HEALTH FAIRS, AND CLASSES. PRHC WILL ALSO PROMOTE EXISTING WALKING TRAILS TO NEIGHBORING COMMUNITIES, INCREASE ACCESS TO HEALTHY FOOD FOR SENIORS, INCLUDING EDUCATION ON READING LABELS, AND CONTINUE TO PROMOTE WIC AND SNAP PROGRAMS.4) PROVIDE INSURANCE PRICE TRANSPARENCY. PRHC WILL MAINTAIN AND DISTRIBUTE CONTACT INFORMATION OF PATIENT ADVOCACY PROGRAMS AND INCREASE WEB PRESENCE OF PATIENT ADVOCATE INFORMATION.5) IMPROVE LOCAL CARDIAC SERVICES. TWO PHYSICIANS COLLABORATE WITH IOWA CLINIC CARDIOLOGY TO INCREASE THE NUMBER OF DAYS AND SERVICES PROVIDEDAT PRHC. A PHYSICIAN WILL COLLABORATE WITH THE IOWA CLINIC CARDIOLOGY TO MANAGE A CHF CLINIC AT PRHC. THE HOURS AND DAYS PER WEEK A CARDIOLOGIST IS AVAILABLE AT PRHC WILL INCREASE TO 5 DAYS PER WEEK. CAPITAL EQUIPMENT WILL BE CONSIDERED FOR TESTING AND DIAGNOSTICS. RN STAFF AND MID-LEVEL PROVIDERS WILL BE TRAINED TO SUPERVISE STRESS TESTS TO INCREASE THE AVAILABLE TIMES FOR SERVICES TO OUR PATIENTS.6) EXPLORE/DEVELOP A STAND ALONE URGENT CARE. EXTEND AFTER HOURS CALL CENTER AND PROVIDE MID-LEVEL SUPPORT FOR EXTENDED HOURS.7) ADDRESS DEMENTIA SERVICES. EDUCATE INDIVIDUALS ON CURRENT SERVICES AVAILABLE IN PELLA. RESEARCH OPPORTUNITIES FOR COLLABORATION WITH ALZHEIMER'S RESEARCH UNIVERSITIES FOR STANDARDIZED TESTING, RESULTS, AND PROVIDE PHYSICIANS WITH SCREENING TOOLS.THE NEED TO PROVIDE MORE AFFORDABLE NURSING HOME OPTIONS AND IMPROVE WATER QUALITY ARE NOT PART OF PELLA REGIONAL'S MISSION OR CORE BUSINESS OPERATIONS. PRHC WILL PARTNER WITH HEARTHSTONE AND VRIENDSCHAP VILLAGE ON ACTIONS FOR NURSING HOME OPTIONS AND CENTRAL COLLEGE ON ACTIONS TO ADDRESS WATER QUALITY. PELLA REGIONAL HEALTH CENTER PART V, SECTION B, LINE 13H: PELLA REGIONAL HEALTH CENTER (HEALTH CENTER) ALSO REVIEWS A PATIENT'S MONTHLY INCOME, EXPENSES, ASSETS, LIABILITIES, PRIOR HEALTH HISTORY, AND TOTAL OUTSTANDING BILLS IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON THE FEDERAL POVERTY GUIDELINES. THE FEDERAL POVERTY GUIDELINES ARE USED AS A STARTING POINT TO DETERMINE FINANCIAL ASSISTANCE, BUT SEVERAL OTHER FACTORS ARE TAKEN INTO CONSIDERATION BEFORE DETERMINING HOW MUCH OF A PATIENT'S BILL WILL BE WRITTEN OFF TO CHARITY CARE IF THE PATIENT'S EARNINGS ARE ABOVE THE 200% FEDERAL POVERTY GUIDELINE BASE AMOUNT.THE HEALTH CENTER ALSO OFFERS UNINSURED PATIENTS A 20% CASH DISCOUNT FOR FINAL BILLS PAID IN FULL WITHIN 60 DAYS. THE HEALTH CENTER DOES NOT CHARGE INTEREST ON UNPAID BALANCES WHEN PAYMENT PLANS ARE SET UP WITHIN 60 DAYS OF PATIENTS RECEIVING THEIR FINAL BILL. PELLA REGIONAL HEALTH CENTER PART V, SECTION B, LINE 20E: IN ADDITION TO THE ACTIONS TAKEN IN PART V, SECTION B, LINE 20A-20D, PELLA REGIONAL HEALTH CENTER SENDS INSUFFICIENT PAYMENT LETTERS TO INDIVIDUALS FOR PAYMENTS NOT MEETING THE HOSPITAL'S MINIMUM PAYMENT REQUIREMENTS. PRHC ALSO SENDS MINIMUM PAYMENTS LETTERS THAT OUTLINED ITS MINIMUM PAYMENT REQUIREMENTS. IF NEEDED, INDIVIDAULS HAVE THE OPTION TO CONSULT A PATIENT ADVOCATE FOR REVIEW OF SERVICE. 14 1 - PELLA MEDICAL CLINIC 405 MONROE PELLA IA 50219 PHYSICIAN CLINIC 2 - OTTUMWA MEDICAL CLINIC 920 N QUINCY AVE OTTUMWA IA 52501 PHYSICIAN CLINIC 3 - KNOXVILLE MEDICAL CLINIC 1208 N LINCOLN KNOXVILLE IA 50138 PHYSICIAN CLINIC 4 - PELLA REGIONAL PHARMACY 802 WASHINGTON ST PELLA IA 50219 RETAIL PHARMACY 5 - HOSPICE OF PELLA (COMFORT HOUSE) 505 UNION STREET PELLA IA 50219 HOSPICE 6 - HOME HEALTH 1119 E 2ND STREET PELLA IA 50219 HOME HEALTHCARE 7 - VERMEER HEALTH SERVICES CENTER 1210 VERMEER ROAD EAST PELLA IA 50219 PHYSICIAN CLINIC 8 - BUSSEY MEDICAL CLINIC 411 MERRILL STREET BUSSEY IA 50044 PHYSICIAN CLINIC 9 - MONROE CLINIC 100 SHERMAN STREET MONROE IA 50170 PHYSICIAN CLINIC 10 - SULLY CLINIC 704 3RD STREET SULLY IA 50251 PHYSICIAN CLINIC 11 - NEW SHARON MEDICAL CLINIC 302 S PARK AVENUE NEW SHARON IA 50207 PHYSICIAN CLINIC 12 - OTTUMWA THERAPY AGENCY 611 NORTH HANCOCK STREET OTTUMWA IA 52501 PHYSICAL AND OCCUPATIONAL THERAPY 13 - ALBIA MEDICAL CLINIC 6580 165TH STREET ALBIA IA 52531 PHYSICIAN CLINIC 14 - CLOW OCCUPATIONAL HEALTH CLINIC 902 S 2ND STREET OSKALOOSA IA 52577 OCCUPATIONAL HEALTH PART I, LINE 3C: PELLA REGIONAL HEALTH CENTER (HEALTH CENTER) ALSO REVIEWS A PATIENT'S MONTHLY INCOME, EXPENSES, ASSETS, LIABILITIES, PRIOR HEALTH HISTORY, AND TOTAL OUTSTANDING BILLS IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON THE FEDERAL POVERTY GUIDELINES. THE FEDERAL POVERTY GUIDELINES ARE USED AS A STARTING POINT TO DETERMINE FINANCIAL ASSISTANCE, BUT SEVERAL OTHER FACTORS ARE TAKEN INTO CONSIDERATION BEFORE DETERMINING HOW MUCH OF A PATIENT'S BILL WILL BE WRITTEN OFF TO CHARITY CARE IF THE PATIENT'S EARNINGS ARE ABOVE THE 200% FEDERAL POVERTY GUIDELINE BASE AMOUNT. THE MEDIAN HOUSEHOLD INCOME IN 2015 WAS $57,173. 9.8% OF PEOPLE WERE LIVING IN POVERTY.THE HEALTH CENTER ALSO OFFERS UNINSURED PATIENTS A 20% CASH DISCOUNT FOR FINAL BILLS PAID IN FULL WITHIN 60 DAYS. THE HEALTH CENTER DOES NOT CHARGE INTEREST ON UNPAID BALANCES WHEN PAYMENT PLANS ARE SET UP WITHIN 60 DAYS OF PATIENTS RECEIVING THEIR FINAL BILL. PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS USED TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, HEALTH PROFESSIONS EDUCATION, LINE 7F, AND CASH AND IN-KIND CONTRIBUTIONS, LINE 7I, ARE REPORTED BASED ON ACTUAL EXPENSE AND REVENUE AMOUNTS RECORDED FROM THE EVENTS IN THE GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, LINE 7G: THE ORGANIZATION USED THE MEDICARE COST REPORT AS WELL AS INTERNAL FINANCIAL STATEMENTS TO CALCULATE A COST-TO-CHARGE RATIO FOR EACH DEPARTMENT THAT CONSTITUTES A SUBSIDIZED HEALTH SERVICE ACTIVITY. THE FOLLOWING PHYSICIAN CLINIC COSTS WERE INCLUDED IN COMMUNITY BENEFIT EXPENSE: PELLA MEDICAL CLINIC - $15,685,070, MONROE CLINIC - $565,678, SULLY CLINIC - $409,574, OTTUMWA CLINIC - $3,720,739, BUSSEY CLINIC - $428,605, AND NEW SHARON CLINIC - $373,659. PART II, COMMUNITY BUILDING ACTIVITIES: INFECTION CONTROL SERVES AS A COMMUNITY BENEFIT AS IT TRACKS INFECTIONS THROUGHOUT THE WORLD, NATION, AND LOCAL AREA IN AN EFFORT TO REDUCE OR PREVENT INCIDENCE OR LOCAL OCCURENCE. ALSO, IT HELPS TO PREPARE FOR THE EVENTUALITY OF INFECTION ISSUES WITHIN THE COMMUNITY AND AT OUR FACILITY. PART III, LINE 2: PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER EVERY EFFORT IS MADE TO COLLECT THE BALANCE AND PATIENTS ARE GIVEN OPPORTUNITIES TO COMPLETECHARITY CARE APPLICATIONS OR SET UP PAYMENT PLANS. ALL DISCOUNTS AND CONTRACTUAL ADJUSTMENTS ARE APPLIED TO ACCOUNTS BEFORE THEY ARE WRITTEN OFF TO BAD DEBT. CURRENT PAYMENTS ON ACCOUNTS PREVIOUSLY WRITTEN OFF AS BAD DEBT REDUCES BAD DEBT EXPENSE.BAD DEBT EXPENSE ON LINE 2 IS REPORTED AT CHARGES AS PRESENTED ON THE FINANCIAL STATEMENTS. PART III, LINE 3: NOT APPLICABLE PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGE 9 AND 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: THE ENTIRE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. PELLA REGIONAL HEALTH CENTER PROVIDES SERVICES TO PATIENTS UNDER THE MEDICARE PROGRAM KNOWING THAT THEY WILL NOT RECOVER ALL OF THE COSTS ASSOCIATED WITH PROVIDING THESE SERVICES. PROVIDING THESE SERVICES IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE. THE ORGANIZATION REPORTED ONLY THOSE ALLOWABLE COSTS AND MEDICARE REIMBURSEMENTS REPORTED IN THE MEDICARE COST REPORT FOR THE YEAR.TOTAL REVENUE RECEIVED FROM MEDICARE (INCLUDING DSH AND IME) IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT (INCLUDING LSA). BOTH THE TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: PELLA REGIONAL HEALTH CENTER'S COLLECTION POLICY HAS PROVISONS FOR PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE OR CHARITY CARE AND FOR PATIENTS IN THE PROCESS OF APPLYING FOR ASSISTANCE. PELLA REGIONAL HEALTH CENTER DOES NOT PURSUE COLLECTION EFFORTS WHILE A PATIENT IS IN THE PROCESS OF APPLYING FOR ANY TYPE OF ASSISTANCE OR FOR ANY PORTION OF A PATIENT'S BILL CONSIDERED CHARITY CARE. AFTER ASSISTANCE IS DETERMINED, ANY PERSONAL PORTION DUE WOULD FOLLOW THE SAME COLLECTION PROCEDURES AS OTHER PATIENTS. IF A PAYMENT PLAN IS ESTABLISHED AND THE PATIENT DEFAULTS, THEIR CHARITY CARE STATUS IS REVOKED AND THE REMAINING BALANCE IS SENT TO COLLECTIONS. PART VI, LINE 2: PELLA REGIONAL HEALTH CENTER PARTICIPATED IN A COMMUNITY ENGAGEMENT PROJECT IN 2011. THIS PROJECT INCLUDED A COMMUNITY HEALTH NEEDS ASSESSMENT, KEY INFORMANT INTERVIEWS, AND SECONDARY DATA ANALYSIS ADMINISTERED BY THE NATIONAL RURAL HEALTH RESOURCE CENTER OF DULUTH, MINNESOTA. THE HEALTH IMPLEMENTATION PLAN (HIP) FROM THE 2011 CHNA WILL BE CLOSED AS OF DECEMBER 31, 2014. A NEW CHNA WAS COMPLETED IN 2014. THIS PROJECT INCLUDED A COMMUNITY HEALTH NEEDS SURVEY, COMMUNITY LEADERS FOCUS GROUP, AND SECONDARY DATA ANALYSIS ADMINISTERED BY THE VVV MARKETING & DEVELOPMENT INC. OF OLATHE, KANSAS.IN APRIL 2014, PELLA REGIONAL BEGAN ITS SECOND COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS. OVER THE SUMMER, A RANDOM, STRATIFIED SAMPLE OF 1,000 RESIDENTS WITHIN PELLA REGIONAL'S SERVICE AREA WAS SURVEYED, AND 225 SURVEYS WERE RETURNED PROVIDING A 22.5 PERCENT RESPONSE RATE. IN ADDITION, A FOCUS GROUP WITH 50 COMMUNITY LEADERS INCLUDING SENIOR CITIZENS, CONSUMERS, HEALTH CARE PROVIDERS/CLINICIANS, EDUCATORS, BUSINESS OWNERS, CLERGY, AND LAW ENFORCEMENT OFFERED QUALITATIVE INFORMATION TO SUPPLEMENT THE SURVEY.THE COMMUNITY HEALTH NEEDS ASSESSMENT IDENTIFIED COMMUNITY HEALTH STRENGTHS AND WEAKNESSES. OUR FORMAL COMMUNITY HEALTH NEEDS ASSESSMENT AND HEALTH IMPLEMENTATION PLAN WAS POSTED TO OUR WEBSITE IN DECEMBER 2014. PART VI, LINE 3: PELLA REGIONAL HEALTH CENTER'S PATIENT ADVOCATES ARE AVAILABLE TO WORK WITH PATIENTS PRIOR TO NON-EMERGENCY SERVICES TO REVIEW SPECIFIC INSURANCE SITUATIONS AND THE DOCTOR'S RECOMMENDED SERVICE FOR THE PATIENT. THE ADVOCATE ESTIMATES EACH PATIENT'S ACTUAL COST AND WORKS WITH THEM TO FIND THE BEST METHOD OF PAYMENT, OR HELP DETERMINE ELIGIBILITY FOR CHARITY CARE FROM PELLA REGIONAL HEALTH CENTER OR THROUGH GOVERNMENT PROGRAMS. PART VI, LINE 4: PELLA REGIONAL HEALTH CENTER (PRHC) IS A CRITICAL ACCESS HOSPITAL THAT OFFERS A LARGE ARRAY OF BOTH INPATIENT AND OUTPATIENT SERVICES. PRHC HAS A RACIALLY HOMOGENOUS SERVICE AREA THAT COVERS MARION, MAHASKA, JASPER, AND WAPELLO COUNTIES IN IOWA. PELLA IS A THRIVING COMMUNITY APPROXIMATELY 40 MILES SOUTHEAST OF DES MOINES, IOWA AND IS HOME TO NOT ONLY PRHC BUT ALSO THE CORPORATE HEADQUARTERS FOR PELLA CORP, A LARGE MANUFACTURER OF WINDOWS AND DOORS, AND VERMEER CORPORATION, THE MANUFACTURER OF INDUSTRIAL AND AGRICULTURAL EQUIPMENT. BOTH COMPANIES ARE KNOWN WORLDWIDE. PELLA IS VERY FORTUNATE TO HAVE THIS TYPE OF INDUSTRIAL AND FINANCIAL BASE. THE POPULATION IN PELLA, IA FOR 2014 WAS 10,337. MEDIANHOUSEHOLD INCOME IN 2013 WAS $59,499 AND THERE WERE 9.7% OF PEOPLE LIVING IN POVERTY. THE UNEMPLOYMENT RATE POPULATION 25 YEARS AND OVER WAS 2.9%. THIS INFORMATION WAS OBTAINED FROM WWW.CITY-DATA.COM/CITY/PELLA-IOWA.HTML. PART VI, LINE 5: THE BOARD MEMBERS ALL RESIDE IN THE SERVICE AREA. A MAJORITY OF THE BOARD MEMBERS ARE NOT EMPLOYED BY PELLA AND NONE ARE FAMILY MEMBERS. PHYSICIANS ARE ENCOURAGED TO PARTICIPATE ON THE BOARD AS THEY HAVE DIRECT CONTACT WITH OUR PATIENTS AND KNOW FIRSTHAND THE NEEDS OF THE COMMUNITY. PELLA REGIONAL HEALTH CENTER EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY EXCEPT FOR PHYSICIANS WITH PENDING QUALITY ISSUES. THE ORGANIZATION APPLIES SURPLUS FUNDS TO IMPROVE PATIENT CARE, MEDICAL EDUCATION, AND RESEARCH THROUGH THE NORMAL BUDGET AND CAPITAL BUDGET PROCESSES. ALSO, PELLA REGIONAL HEALTH CENTER PROMOTES THE HEALTH OF THE COMMUNITY BY OPERATING AN EMERGENCY ROOM AVAILABLE TO ALL REGARDLESS OF ABILITY TO PAY, PARTICIPATING IN GOVERNMENT-SPONSORED HEALTH PROGRAMS AND VOLUNTEERING IN THE COMMUNITY. PART VI, LINE 7, REPORTS FILED WITH STATES IA X X X 0 0 0 0 0 0 0 1 0 DOUG KANIS DO DIRECTOR 387909 0 0 0 2370 0 15900 0 21316 0 427495 0 0 0 CRAIG WITTENBURG MD DIRECTOR 455127 0 0 0 2538 0 15900 0 24834 0 498399 0 0 0 BRUCE HEIFNER CHIEF FINANCIAL OFFICER 155131 0 6033 0 793 0 7787 0 16561 0 186305 0 0 0 ROBERT KROESE CHIEF EXECUTIVE OFFICER 275357 0 10684 0 2046 0 15900 0 18070 0 322057 0 0 0 YVONNE O'BRIEN-EVANS CHIEF NURSING OFFICER 156160 0 0 0 1254 0 9566 0 8121 0 175101 0 0 0 MICHAEL THOMPSON DO DIRECTOR 413913 0 0 0 2382 0 15900 0 21715 0 453910 0 0 0 CHARLES CANEDY MD PHYSICIAN 397846 0 0 0 24303 0 15900 0 20888 0 458937 0 0 0 SPENCER CARLSTONE MD PHYSICIAN 389295 0 0 0 2382 0 15900 0 21661 0 429238 0 0 0 JOSEPH COLEMAN MD PHYSICIAN 360297 0 0 0 2538 0 15900 0 22017 0 400752 0 0 0 DALE LENSING MD PHYSICIAN 357442 0 0 0 2276 0 15900 0 24572 0 400190 0 0 0 MATTHEW MORGAN DO PHYSICIAN 532947 0 0 0 2382 0 15900 0 21661 0 572890 0 0 0 PART I, LINE 7 BONUSES ARE DETERMINED AND PAID OUT BASED ON A PERCENTAGE OF THE EMPLOYEE'S ANNUAL INCOME. THE PERCENTAGE UTILIZED IS DERIVED FROM MEETING THE OVERALL QUALITY, SERVICE, PEOPLE, GROWTH AND FINANCIAL STRATEGIC PLAN BENCHMARKS SET SPECIFICALLY FOR THE ORGANIZATION. THE ORGANIZATION ALSO BENCHMARKS AGAINST THE IOWA HOSPITAL ASSOCIATION'S SALARY AND BENEFIT GUIDELINES. A IOWA FINANCE AUTHORITY 521699886 462466BL6 2006-09-28 46610641 REMODELING PROJECT AND REFUND BONDS ISSUED 12/26/2000 AND 1/1/2002 0 0 0 A 46610641 3286500 601579 1916534 33345532 7460496 2009 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 A 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: IOWA FINANCE AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 12/01/2015 SCHEDULE K, PART II, LINE 11: THE OTHER SPENT PROCEEDS WERE USED TO CURRENTLY REFUND BONDS ON SEPTEMBER 28, 2006. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE IS COMPOSED OF THE PRESIDENT, VICE PRESIDENT, SECRETARY, AND TREASURER. THE COMMITTEE ACTS FOR THE BOARD OF TRUSTEES AND DIRECTS AND CONTROLS THE AFFAIRS OF THE CORPORATION DURING THE INTERIM BETWEEN BOARD MEETINGS BUT IS SUBJECT TO THE SUPERVISION OF THE BOARD AND PROVIDED ANY ACTION TAKEN DOES NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD. THE EXECUTIVE COMMITTEE KEEPS AN ACCURATE AND COMPLETE RECORD OF ALL OF ITS PROCEEDINGS AND THE RECORD MUST BE SUBMITTED FOR CONFIRMATION TO THE BOARD OF TRUSTEES AT THE BOARD'S NEXT MEETING AND MADE A PART OF THE MINUTES. THE EXECUTIVE COMMITTEE HAS THE RIGHT TO APPROVE OR REJECT THE CEO'S RECOMMENDATIONS ON EMPLOYMENT OF PERSONNEL, PLAN OF INTERNAL ORGANIZATION OF THE CORPORATION, AND RULES AND REGULATIONS DEFINING DUTIES, HOURS AND INTERDEPARTMENTAL RELATIONSHIPS OF PERSONNEL. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS DISTRIBUTED TO THE BOARD'S FINANCE COMMITTEE AND PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING. IT IS ALSO REVIEWED BY THE CEO AND CFO. FORM 990, PART VI, SECTION B, LINE 12C PELLA REGIONAL HEALTH CENTER HAS CONFLICT OF INTEREST POLICIES COMPLETED EACH YEAR BY ALL BOARD MEMBERS AND OFFICERS THUS MONITORING ANY POTENTIAL CONFLICTS OF INTEREST. THE CEO AND CFO REVIEW THE COMPLETED STATEMENTS. IF A POTENTIAL CONFLICT IS IDENTIFIED, THE CEO FOLLOWS UP. ANY ACTUAL OR POTENTIAL DUALITY OR CONFLICT OF INTEREST, INCLUDING BUT NOT LIMITED TO, OWNERSHIP OR CONTROL OF ANY ENTITY THAT CONTRACTS WITH PELLA REGIONAL HEALTH CENTER FOR ANY PRODUCTS OR SERVICES MUST BE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD IN THE MINUTES WHEN THE SUBJECT OF SUCH INTEREST BECOMES A MATTER OF BOARD ACTION. WHEN CONFLICT ARISES, THE MEMBER IS ASKED TO BE EXCUSED FROM THE MEETING. FORM 990, PART VI, SECTION B, LINE 15A THE CEO'S COMPENSATION IS SET BY THE EXECUTIVE COMMITTEE OF THE BOARD WITH SALARY ADJUSTMENT RECOMMENDATIONS BASED ON AN ANNUAL EVALUATION AND INPUT FROM HUMAN RESOURCES. THE COMPENSATION FOR OTHER OFFICERS AND KEY EMPLOYEES IS SET BY THE CEO WITH SALARY ADJUSTMENTS BASED ON ANNUAL EVALUATIONS AND DIRECTION FROM HUMAN RESOURCES. COMPARABILITY DATA IS USED TO DETERMINE COMPENSATION FOR TOP MANAGEMENT OFFICIALS, OFFICERS, AND EMPLOYEES IN NON-MANAGEMENT POSITIONS. SEVERAL SURVEYS ARE USED FOR COMPARABILITY INCLUDING THE IOWA HOSPITAL ASSOCATION, IOWA HEALTH SYSTEM, IOWA INTEGRATED HEALTHCARE STRATEGIES, COMPDATA SURVEYS, IOWA ASSOCIATION OF HOMES AND SERVICES FOR THE AGING, IOWA MEDICAL GROUP MANAGEMENT ASSOCIATION, AND SOUTHEAST IOWA COMP CLUB. THE ORGANIZATION DOCUMENTS AND PROVIDES SUBSTANTIATION FOR ITS COMPENSATION PROCESS FOR ALL EMPLOYEES. THIS PROCESS WAS LAST UNDERTAKEN IN 2016. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST. FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC AS THEY ARE ATTACHED TO THE FORM 990. FORM 990, PART VII, SECTION A: THE PHYSICIANS/DIRECTORS ARE COMPENSATED FOR THEIR SERVICES AS PHYSICIANS. THEIR TIME SERVED AS BOARD MEMBERS IS ON A VOLUNTEER BASIS AND NO COMPENSATION IS RECEIVED FOR THOSE SERVICES. FORM 990, PART XII, LINE 2C: THE OVERSIGHT AND SELECTION PROCESS HAS NOT CHANGED FROM PRIOR TAX YEARS. PELLA HOSPITAL FOUNDATION 404 JEFFERSON STREET PELLA IA 50219 421430122 SOLICIT FUNDS AND SUPPORT PELLA REGIONAL HEALTH CENTER IA 501(C)(3) LINE 7 PELLA REGIONAL HEALTH CENTER 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 PELLA HOSPITAL FOUNDATION C 189904 FAIR MARKET VALUE